Blood Transfusion

Question 1

Universal Donor/Recipient

Answer 1

Donor : O-
Plasma Donor: AB+
Recipient: AB+
Plasma Recipient: O-

Question 2

Rh System

Answer 2

46 rhesus red cell surface antigens 
with D rhesus antigen = Rh+
will not develop the antibody unless exposed 
- transfusion of Rh+ to an Rh- 
-pregnancy with an Rh+ baby to a Rh- mom

Question 3

Compatibility Testing

Answer 3

ABO-Rh: 5 min, 0.2% risk of reaction after this. ABO incompatibility = most severe transfusion reactions

Antibody screen: to detect non-ABO antigens, 45 min

Crossmatch: mimics transfusion, 45 mins. ensures optimal safety. detects low titer antibodies

Question 4

Emergency Transfusion without crossmatch

Answer 4

• if known blood type partial 5 min abbreviated crossmatch, confirms ABO
• if unknown O - uncrossmatched (will contain some anti-A anti-B antibodies)
• after 2+ units transfused of O - must continue with it

Question 5

Massive Transfusion Protocol

Answer 5

1:1:1 RBC: FFP: Platelets
fibrinogen 10 units should increase by 75mg/dL
TXA 1g during infusion, 1 g within 8 hrs after. max
Calcium 1 round (6units RBCs) 1gCaCl or 3g CaGlucaonte

Question 6

Normals -PT, PTT, Fibrinogen

Answer 6

11-13
25-35
130-330

Question 7

FFP

Answer 7

All plasma proteins + all coag factors + fibrinogen

Question 8

FFP Indications

Answer 8

Urgent reversal of warfarin 5-8ml/kg
PT > 1.5x normal (>18)
PTT > 1.5x normal (>55)
Antithrombin III deficiency 
Massive Blood Transfusion 
C1 Esterase Deficiency 
DIC 
Coag factor assay < 25% (10-20ml/kg coagulopathy)

Question 9

Platelets

Answer 9

thrombocytopenia < 50,000
eye & neurosurgery < 100,000
known platelet dysfunction

Question 10

Platelets Considerastions

Answer 10

bacterial infection - sepsis risk stored at room temp (5 days)
1 pack per 10kg of weight
1 unit increase by 10,000
loose ability to aggregate when refrigerated

Question 11

Cryoprecipitate

Answer 11

fibrinogen, vWB, factor VIII & XIII
VIII - is antihemophillic factor

cryo is slow thawed FFP

Question 12

Cryo Indications

Answer 12

Hemophilia A
vWB disease
consumption coagulopathy - main use
fibrinogen deficiency (<80-100mg/dL)

Question 13

Cryo considerations

Answer 13

5 bag pool
admin through filter
complete within 6 hrs of thawing

Question 14

Whole Blood

Answer 14

RBCs
WBCs
Plasma 
Platelet debris 
Fibrinogen 

RBC & blood volume replacement

Question 15

Fibrinogen

Answer 15

factor I
dose 70 mg/kg
adverse reaction - HA, erythema, N/V, fever, weakness

Question 16

Prothrombin Complex Concentrates (Kcentra)

Answer 16

factor IX (II, VII, X)
hemophilia B
reversal of anticoagulant agents (warfarin)

Question 17

DDAVP - desmopressin

Dose and MOA

Answer 17

0.3 mcg/kg
stimulates release of vWF 
releases tPA
2-20 fold increase in VIII - speeds activation of X by IXa
releases prostacyclin

Question 18

DDAVP indications

Answer 18

hemophilia A & vWB disease

ASA induced platelet dysfunction

Question 19

Recombinant Factor VII

Answer 19

enhances thrombin generation on active platelets
approved for hemophilia A
has thrombotic complications

Question 20

Aminocaporic Acid (AMICAR)
Dose and MOA

Answer 20

synthetic lysine inhibitor of plasminogen.
inhibits fibrinolysis - significant reduction in blood loss & transfusion requirements
dosing: 100mg/kg max 5g over 15 min
OR 10mg/kg/hr throughout surgery

Question 21

Tranexamic Acid

Answer 21

competitive inhibitor of plasminogen.

rate of DVT unaffected. blood loss in surgery decreased and transfusion requirement decreased.

Question 22

Hydroxylethyl Starch

Answer 22

Volume expander - polysaccharide
Improve blood rheology - biophysical properties and flow
Acute normovolemic hemodilution

Side Effect: coagulopathy (decreases VIII & vWF)

Question 23

Dextran

Answer 23

Glucose polymer water soluble
Replace intravascular volume
Stays for 12 hrs
Colloid osmotic pressure 340

Side Effects: allergic reactions, increased bleeding time (decreases platelet adhesion), non cardiogenic pulmonary edema

Question 24

Acute Normovolemic Hemodilution

Answer 24

Removal of pt whole blood prior to surgery & replacement with non red cell volume.

Improves oxygenation
Prevents hemostasis.

Criteria: high transfusion liklihood, Hgb<12, no infection or significant comorbidities

Question 25

Transfusion Reaction S/S

Answer 25

Seen under anesthesia: hemoglobinuria, hypotension, fever, flushing, bleeding Masked by anesthesia: dyspnea, chills, nausea, chest pain

Question 26

Transfusion Reaction Manifestations

Answer 26

AKI - free hgb in renal tubules = mechanical obstruction. acidic urine increases precipitation DIC- erythrocin released from RBC activates intrinsic clotting cascade. uncontrolled fibrin formation. consumption of factors I, II, V, VII Hemodynamic Instability: free hgb activates kalikrinen system = bradykinin. vasodilation

Question 27

Treating transfusion reaction

Answer 27

``` stop transfusion alkalize urine - bicarb maintain UOP : IVF, mannitol, lasix sen during & plasma hgb samples to lab check PT, PTT, fibrinogen send unused blood to bank support hemodynamics ```

Question 28

Troublesome Events of blood transfusion

Answer 28

``` alloimmunization HLA antigens allergic and febrile reactions ABT - related mortality (TRALI, TAS, HTI, TTI) intravascular hemolysis ```

Question 29

TRALI

Answer 29

indicated with all plasma contains products - primarily PRBCs despite small amount of plasma. donor anti-HLA antibodies = neutrophil chemotaxis = endothelial damage & capillary leak - Non-cardiogenic pulmonary edema, dyspnea, cough, fever -commonly mistaken for TACO - seen more with blood from multipara women

Question 30

Hemolytic Transfusion Reactions

Answer 30

ABO antigens or other RBC antigens - donor RBCs ar attack by recipients antibodies - acute within 24 hrs - delayed > 24 hrs

Question 31

TRIM - transfusion related immodulation

Answer 31

occurs against HLA antigens nonspecific and antigen specific immunosuppression impaired T cells & decreased macrophages altered cytokines - IL 1, IL8, TNF - primary cause is leukocytes within the cells (most PRBCs are leukocyte reduced) = better outcomes in renal allografts may increase tumor reoccurrence

Question 32

Adaptation to Anemia

Answer 32

- oxyhemoglobin shift R - increase 2,3 DPG - CO increases - microvasculature alterations - tone - RAAS - retain Na+ & water

Question 33

Impact of Pre-op anemia on post-op outcomes

Answer 33

adverse renal and neurological outcomes o Pre-op anemia and intraoperative blood transfusion are both independent risk factors for adverse outcomes o Incidence increase with the increase in number of units transfused

Question 34

Banked Blood

Answer 34

``` metabolic acidosis - high lactate, low pH low 2,3 DPG low ATP low GSH (antiox) low SNO hb Ical & Mag = 0 ```

Question 35

Physical Changes Banked Blood

Answer 35

decreased deformability membrane area decreased 30% dead on arrival

Question 36

Oxidative Issues banked blood

Answer 36

Hgb oxidation - methgb Hgb denaturation = free radicals Bioactive substances in supernatant - cytokines, histamines, lipids, HLA